Development and validation of a semi-automated surveillance system—lowering the fruit for non-ventilator-associated hospital-acquired pneumonia (nvHAP) prevention

Wolfensberger, Aline; Jakob, Werner; Hesse, Mirjam Faes; Kuster, Stefan P.; Meier, Angela; Schreiber, Peter W.; Clack, Lauren; Sax, Hugo

doi:10.1016/j.cmi.2019.03.019

Cited by 13 publications

(21 citation statements)

References 20 publications

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“…By using an EHR-based surveillance definition to identify patients at-risk for NV-HAP, they were able to rule out NV-HAP in 94% of patients and significantly reduce the workload of manual review with high sensitivity and negative predictive value (NPV). 21 Similar to our study, Ramirez Battle et al 7 found similar accuracy of electronic surveillance criteria for NV-HAP and CDC-NHSN criteria relative to expert chart review at a single center among 120 cases with oxygen deterioration. The electronic surveillance definition demonstrated sensitivity of 71%, PPV of 48%, and NPV of 90%.…”

Section: Discussionsupporting

confidence: 89%

“…To address problems with diagnosis codes and manual evaluation of medical records, others have begun to develop approaches that either augment or replace these approaches. Wolfensberger et al 21 validated a semi-automated surveillance system for NV-HAP. By using an EHR-based surveillance definition to identify patients at-risk for NV-HAP, they were able to rule out NV-HAP in 94% of patients and significantly reduce the workload of manual review with high sensitivity and negative predictive value (NPV).…”

Section: Discussionmentioning

confidence: 99%

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Electronic surveillance criteria for non–ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity

Stern

Christensen

Nevers

et al. 2023

Infect. Control Hosp. Epidemiol.

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Objective: Surveillance of non–ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses. Methods: We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans’ Affairs (VA) hospitals from January 1, 2015, to November 30, 2020. We randomly selected 250 hospitalizations meeting NV-HAP surveillance criteria for independent review by 2 clinicians and calculated the percent of hospitalizations with (1) clinical deterioration, (2) CDC National Healthcare Safety Network (CDC-NHSN) criteria, (3) NV-HAP according to a reviewer, (4) NV-HAP according to a treating clinician, (5) pneumonia diagnosis in discharge summary; and (6) discharge diagnosis codes for HAP. We assessed interrater reliability by calculating simple agreement and the Cohen κ (kappa). Results: Among 3.1 million hospitalizations, 14,023 met NV-HAP electronic surveillance criteria. Among reviewed cases, 98% had a confirmed clinical deterioration; 67% met CDC-NHSN criteria; 71% had NV-HAP according to a reviewer; 60% had NV-HAP according to a treating clinician; 49% had a discharge summary diagnosis of pneumonia; and 82% had NV-HAP according to any definition according to at least 1 reviewer. Only 8% had diagnosis codes for HAP. Interrater agreement was 75% (κ = 0.50) for CDC-NHSN criteria and 78% (κ = 0.55) for reviewer diagnosis of NV-HAP. Conclusions: Electronic NV-HAP surveillance criteria correlated moderately with existing manual surveillance criteria. Reviewer variability for all manual assessments was high. Electronic surveillance using clinical data may therefore allow for more consistent and efficient surveillance with similar accuracy compared to manual assessments or diagnosis codes.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Electronic surveillance criteria for non–ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity

Stern

Christensen

Nevers

et al. 2023

Infect. Control Hosp. Epidemiol.

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“…We estimated that NV-HAP could be associated with up to 7.3% of hospital deaths. The incidence and crude individual mortality of NV-HAP was within the range reported in previous studies using point prevalence, manual, or semi-automated approaches . However, this study is the first to generate population-level estimates of the incidence, variation, outcomes, and attributable mortality of NV-HAP using an electronic clinical surveillance definition.…”

Section: Discussionsupporting

confidence: 64%

Incidence and Outcomes of Non–Ventilator-Associated Hospital-Acquired Pneumonia in 284 US Hospitals Using Electronic Surveillance Criteria

Jones,

Sarvet,

Ying

et al. 2023

JAMA Netw Open

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ImportanceNon–ventilator-associated hospital-acquired pneumonia (NV-HAP) is a common and deadly hospital-acquired infection. However, inconsistent surveillance methods and unclear estimates of attributable mortality challenge prevention.ObjectiveTo estimate the incidence, variability, outcomes, and population attributable mortality of NV-HAP.Design, Setting, and ParticipantsThis cohort study retrospectively applied clinical surveillance criteria for NV-HAP to electronic health record data from 284 US hospitals. Adult patients admitted to the Veterans Health Administration hospital from 2015 to 2020 and HCA Healthcare hospitals from 2018 to 2020 were included. The medical records of 250 patients who met the surveillance criteria were reviewed for accuracy.ExposuresNV-HAP, defined as sustained deterioration in oxygenation for 2 or more days in a patient who was not ventilated concurrent with abnormal temperature or white blood cell count, performance of chest imaging, and 3 or more days of new antibiotics.Main Outcomes and MeasuresNV-HAP incidence, length-of-stay, and crude inpatient mortality. Attributable inpatient mortality by 60 days follow-up was estimated using inverse probability weighting, accounting for both baseline and time-varying confounding.ResultsAmong 6 022 185 hospitalizations (median [IQR] age, 66 [54-75] years; 1 829 475 [26.1%] female), there were 32 797 NV-HAP events (0.55 per 100 admissions [95% CI, 0.54-0.55] per 100 admissions and 0.96 per 1000 patient-days [95% CI, 0.95-0.97] per 1000 patient-days). Patients with NV-HAP had multiple comorbidities (median [IQR], 6 [4-7]), including congestive heart failure (9680 [29.5%]), neurologic conditions (8255 [25.2%]), chronic lung disease (6439 [19.6%]), and cancer (5,467 [16.7%]); 24 568 cases (74.9%) occurred outside intensive care units. Crude inpatient mortality was 22.4% (7361 of 32 797) for NV-HAP vs 1.9% (115 530 of 6 022 185) for all hospitalizations; 12 449 (8.0%) were discharged to hospice. Median [IQR] length-of-stay was 16 (11-26) days vs 4 (3-6) days. On medical record review, pneumonia was confirmed by reviewers or bedside clinicians in 202 of 250 patients (81%). It was estimated that NV-HAP accounted for 7.3% (95% CI, 7.1%-7.5%) of all hospital deaths (total hospital population inpatient death risk of 1.87% with NV-HAP events included vs 1.73% with NV-HAP events excluded; risk ratio, 0.927; 95% CI, 0.925-0.929).Conclusions and RelevanceIn this cohort study, NV-HAP, which was defined using electronic surveillance criteria, was present in approximately 1 in 200 hospitalizations, of whom 1 in 5 died in the hospital. NV-HAP may account for up to 7% of all hospital deaths. These findings underscore the need to systematically monitor NV-HAP, define best practices for prevention, and track their impact.

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“…If an invasive respiratory device was present in the 48 h preceding symptom onset, the pneumonia is considered a ventilator-associated pneumonia and thus not subject of this study. A validated semi-automated surveillance system for nvHAP is used [28]. Place of nvHAP acquisition is defined as department, ward and room to which the patient was affiliated 48 h before first symptoms of nvHAP, unless shorter incubation period is evident from patient history.…”

Section: Quantitative Data Collectionmentioning

confidence: 99%

Implementation and evaluation of a care bundle for prevention of non-ventilator-associated hospital-acquired pneumonia (nvHAP) – a mixed-methods study protocol for a hybrid type 2 effectiveness-implementation trial

et al. 2020

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Background: Hospital acquired pneumonia (HAP) is divided in two distinct groups, ventilator-associated pneumonia (VAP) and non-ventilator-associated HAP (nvHAP). Although nvHAP occurs more frequently than VAP and results in similar mortality and costs, prevention guidelines and prevention focus almost exclusively on VAP. Scientific evidence about nvHAP prevention and its implementation is scarce. Therefore, we designed a mixedmethods hybrid type 2 effectiveness-implementation study to investigate both the effectiveness and implementation of a newly developed nvHAP prevention bundle. Methods: This single-centre project at the 950-bed University Hospital Zurich (UHZ) will engage the wards of nine departments with substantial nvHAP rates. The nvHAP bundle consists of five primary prevention measures: 1) oral care, 2) prevention of dysphagia-related aspiration, 3) mobilization, 4) stopping unnecessary proton pump inhibitors, and, 5) respiratory therapy. Implementation includes the engagement of department-level implementation teams, who sustain the 'core' intervention components of education, training, and environmental restructuring and tailor the implementation strategy to local needs. Both effectiveness and implementation outcomes will be assessed using mixed-methods. As a primary outcome, nvHAP incidence rates will be analysed by Poisson regression models to compare incidence rates before, during, and after the implementation phases (on the hospital and department level). Additionally, the association between process indicators and nvHAP incidence rates will be analysed using longitudinal Poisson regression models. A longitudinal, qualitative study and formative evaluation based on

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Development and validation of a semi-automated surveillance system—lowering the fruit for non-ventilator-associated hospital-acquired pneumonia (nvHAP) prevention

Cited by 13 publications

References 20 publications

Electronic surveillance criteria for non–ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity

Electronic surveillance criteria for non–ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity

Incidence and Outcomes of Non–Ventilator-Associated Hospital-Acquired Pneumonia in 284 US Hospitals Using Electronic Surveillance Criteria

Implementation and evaluation of a care bundle for prevention of non-ventilator-associated hospital-acquired pneumonia (nvHAP) – a mixed-methods study protocol for a hybrid type 2 effectiveness-implementation trial

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